Millions of Americans have run into the experience of filing a health insurance claim only to have it quickly denied. Utilizing computer algorithms or individuals with little relevant experience to issue mass denials of insurance claims has become increasingly popular among insurers. This is a way for insurers to keep profits high, yet is exactly what provisions of the Affordable Care Act (ACA) aim to prevent.
The Department of Health and Human Services (HHS) has been tasked with monitoring the denials provided by employers and insurers and by health plans on the Obamacare marketplace yet has not fulfilled this duty.
A recent KFF study of ACA plans revealed that in 2021, companies denied 17 percent of claims on average, even when patients received care from in-network physicians. In 2021, one insurer denied 49 percent of claims, and another denied 80 percent in 2020. Data reveals that only one out of every 500 cases is appealed, despite the negative impact denials can have on an individual’s health or finances.
A ProPublica investigation of Cigna discovered an automated system, known as PXDX, that allowed Cigna medical reviewers to rapidly sign off—and issue denials—on charts without having to examine patient records.
Under the ACA, the HHS “shall” collect denial data from private health insurers and group health plans, and this information should be publicly available, yet this process has been unorganized and limited, without a data audit to ensure the information-gathering is complete. The government has both the power and the duty to end these reckless denials, and it may be time for mandated investigation and enforcement to begin.
The full article can be found here.
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Last Updated on June 27, 2023 by Aimed Alliance
